Reasons to use e-cigarettes among adults and youth in the Population Assessment of Tobacco and Health (PATH) study
Introduction
The popularity of electronic cigarettes (e-cigarettes) has risen sharply in recent years (Jamal et al., 2016). In 2015, 7.9 million adults were past 30-day e-cigarette users (Jamal et al., 2016), and e-cigarettes were the most popular tobacco product among middle and high school students (Singh, Arrazola, Corey, & Al, 2016). E-cigarettes frequently contain nicotine, which is addictive, and harmful toxicants, including formaldehyde (Logue et al., 2017). Further, associations between e-cigarette use and future cigarette use among youth are well established (England, Bunnell, Pechacek, Tong, & McAfee, 2015; Friedman, 2015; Leventhal et al., 2015; National Academies of Sciences Engineering and Medicine, 2018; Primack, Soneji, Stoolmiller, Fine, & Sargent, 2015). U.S. policymakers have taken steps to prevent e-cigarette initiation, including restricting sales to minors; however, effective tobacco control requires a comprehensive understanding of the reasons youth and adults find e-cigarettes desirable.
Early studies on the reasons that youth and adults use e-cigarettes relied heavily on focus groups (Choi, Fabian, Mottey, Corbett, & Forster, 2012; Pepper & Brewer, 2014; Pokhrel, Herzog, Muranaka, Regmi, & Fagan, 2015), while later studies examined whether reasons to use e-cigarettes are associated with patterns of use (Adkison et al., 2013; Bold, Kong, Cavallo, Camenga, & Krishnan-Sarin, 2016; Kong, Morean, Cavallo, Camenga, & Krishnan-Sarin, 2015; Pepper, Ribisl, Emery, & Brewer, 2014; Tan, Lee, & Bigman, 2016). Common reasons to use e-cigarettes cited by youth and adults were curiosity, peer influences, and ability to use anywhere (Bold et al., 2016; Choi et al., 2012; Kong et al., 2015). Adults also cited more goal-directed reasons, such using them to quit or reduce cigarette smoking and being less harmful than cigarettes (Adkison et al., 2013; Bold et al., 2016; Pepper et al., 2014). Additional youth-specific reasons were that e-cigarettes were “cool”, had appealing flavors, were easy to hide, were cheaper, and did not smell like cigarettes (Bold et al., 2016; Choi et al., 2012; Kong et al., 2015). Previous research assigned these reasons to general categories, such as “general interest” and “social norms”, to organize related items. For example, “social norms” is commonly assigned as the larger category that cites friends/peers/family using e-cigarettes and e-cigarettes can be used anywhere (Bold et al., 2016; Kong et al., 2015; Tan et al., 2016).
Conversely, reasons to use cigarettes are well-defined (Lewis-Esquerre, Rodrigue, & Kahler, 2005; Rash & Copeland, 2008; US Department of Health and Human Services, 2014). Latent themes developed from social-learning theory, including “expectancy” and “coping”, help explain why individuals smoke cigarettes (US Department of Health and Human Services, 2014). These larger concepts (e.g. expectancies about the rewards that will occur from using tobacco) were developed from factor analyses into validated questionnaires, including the Smoking Consequences Questionnaire (Lewis-Esquerre et al., 2005; Rash & Copeland, 2008). Thus, cigarette research has provided a framework of theory and evidence on reasons to use cigarettes, which have been targeted by effective tobacco interventions (US Department of Health and Human Services, 2014).
The purpose of this study is to determine the underlying themes of reasons to use e-cigarettes and to examine the associations between these reasons and user characteristics, including examining youth and adults separately. This study contributes to the literature on reasons to use e-cigarettes by employing exploratory factor analysis (EFA) that assumes no latent a priori structure among thirteen reasons to use to identify constructs that best describe the observed patterns motivating use. This factor structure refines our understanding on how reasons to use e-cigarettes share commonality among youth and adults and uses nationally representative data to tailor tobacco prevention and control programs.
Section snippets
Methods
Data are from 13,651 youth (12–17 years) and 32,320 adults (18 years and older) in the US surveyed in Wave 1 (September 2013–December 2014) of the PATH Study, a nationally representative, longitudinal cohort. Parents/Guardians (n = 13,588) completed a Parent Interview focusing on their child's health and tobacco use. Over 150,000 mailing addresses were used to sample tobacco users and non-users, where an in-person household screener determined participant selection. Up to two adults and two
Adults
Among adult e-cigarette users, the majority were current experimental users (51.4%), had smoked cigarettes in the past 30 days (81.7%), and were non-Hispanic White (71.2%). More e-cigarette users were between the ages of 25 and 34 (26.9%) and fewer users were over the age of 65 (4.7%). Most adult users earned a high school diploma/GED or less (47.4%) and had an annual income of $10,000–$24,999 (25.6%).
Discussion
This study provided insight into the reasons youth and adults use e-cigarettes that is congruent with previous research, while also expanding the literature by describing a two-factor structure (“alternative to cigarettes” and “larger social environment”) that organizes reasons to use items based on underlying commonality among response patterns. Like previous studies, youth and adults in this study were both highly influenced by sub-categories such as general interest, peer influences, social
Acknowledgement
NEN is supported by P50DA036105 from the National Institute on Drug Abuse of the National Institutes of Health and the Center for Tobacco Products of the US Food and Drug Administration and by T32CA093423 from the National Cancer Institute of the National Institutes of Health. AJB is supported by R03DA04005 from the National Institute on Drug Abuse of the National Institutes of Health and the Center for Tobacco Products of the US Food and Drug Administration, 5UG1CA189869 from the National
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